Ophthalmology and Optometry Coding Alert

Learn the rules of the altered -GA modifier (Waiver of liability statement on file) and the new HCPCS modifiers -GY and -GZ or you could end up footing the bill for the next cosmetic blepharoplasty you perform.

A blepharoplasty, 15820-15823, is just one of the many ophthalmological services that might be classified and denied as "not reasonable or necessary" according to Medicare, thereby necessitating the use of modifier -GA when a signed advance beneficiary notice is obtained.

The premise that the beneficiary signed an ABN is a crucial element when identifying codes that require modifier -GA. The new advance beneficiary notices introduced by Medicare effective July 1 are part of CMS' beneficiary notices initiative (BNI). While the revised ABNs serve the same function of advising beneficiaries about receiving items that they may have to pay for themselves, the new ABNs are an attempt to define patient options more clearly and to be more reader-friendly for beneficiaries.

For example, a patient presents with excessive skin of the right eyelid but it does not cause impaired vision or fit the criteria of medical necessity established by the carrier local medical review policies. The ophthalmologist decides that the procedure is not medically necessary and is therefore cosmetic. The patient is then presented with an advance beneficiary notice, which he signs. The physician performs a blepharoplasty of the extra upper eyelid skin, 15822 (Blepharoplasty, upper eyelid). This procedure should now be billed 15822-GA-RT.

The -GA modifier should also be applied to visual field tests that correspond to diagnosis codes that are not covered. For example, if a fluorescein angiogram code (92235) is paired with a blurred vision diagnosis code such as 368.8, a code that does not constitute medical necessity according to most LMRPs, modifier -GA should be appended.

According to CMS, -GA may also be used when assigned and unassigned claims for DMEPOS fall under certain Part B "technical denials" prohibited telephone solicitation, no supplier number, and failure to obtain an advance determination of coverage.

CMS provides three scenarios that require the use of modifier -GA:
 

When you think a service will be denied because it does not meet the Medicare program standards for medically necessary care and you gave the beneficiary an ABN

Anytime you obtain a signed ABN or have a patient's refusal to sign an ABN witnessed properly in an assigned-claim situation (with the exception of an assigned claim for one of the specified DMEPOS technical denials)
 

On an assigned claim if you gave an ABN to a patient but the patient refused to sign it and you did furnish the services.

Other instances in which -GA might be used include "many ptosis procedures in an eye plastic practice or Botox for wrinkles," says Michael X. Repka, MD, AAO representative to the American Medical Association's CPT advisory committee.

John S. Bell, CEO, CMPE, says the ophthalmologists and coders of Maine Eye Care Associates based in Waterville, Maine, have "long used the -GA modifier, especially for postcataract glasses when the patient wants to get the extras not covered by Medicare."

While appending -GA when it is irrelevant will not hurt your chances of being reimbursed for a covered procedure, you could be penalized for failure to use modifier -GA when a code requires it. If you don't use -GA and the claim is denied, you will have to send a corrected claim with -GA and proof that you obtained an ABN, or you will neither be paid nor be permitted to collect from the beneficiary, according to Medicare.

Don't Exclude Modifier -GY

When you know in advance that a claim will be denied as either a "statutory exclusion" or a "technical denial" and the service procured to the beneficiary did not require an ABN, using modifier -GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) could speed up getting your reimbursement from a secondary insurer.

If you submit a claim that you expect will be denied because it is not a Medicare benefit, or Medicare law specifically excludes it, or the service does not meet all the requirements of the definition of a benefit in Medicare law or if you have submitted a claim to obtain a Medicare denial for secondary-payer purposes -GY could make this process easier.

For example, you can expect denials for a claim for a patient undergoing cosmetic blepharoplasty or a claim for a patient who presents with subfoveal occult age-related macular degeneration with no classic choroidal neovascular-ization. Therefore, you should append -GY.

One benefit of appropriately appending -GY is that the claim will be denied by Medicare, and the carrier may even "auto-deny" -GY-modified claims, thus making your eventual reimbursement a quicker reality.

"It is nice to have the -GY modifier for those patients who insist that we file charges for a refraction with Medicare so that they can get it paid by their secondary payer," Bell says.

Volunteer -GZ to Avoid Fraud Charges

Think of modifier -GZ (Item or service expected to be denied as not reasonable and necessary) as your "Get Out of Jail Free" card when you are billing for a service that does not meet Medicare's standards for reimbursement and you did not obtain a signed ABN from the beneficiary.

Modifier -GZ has a similar description to that of -GA since they are both applied to claims with expected "medical necessity" denials. But -GZ has a unique attribute it's voluntary.

Medicare recommends using -GZ to "physicians and suppliers that wish to submit a claim to Medicare, that know that an ABN should have been signed but was not, and that do not want any risk of allegation of fraud or abuse for claiming services that are not medically necessary," but it is not a mandated policy.

CMS offers some examples of when to use -GZ:

When you were unable to give the patient an ABN due to an emergency, e.g., in an EMTALA-covered situation in an emergency room, or in an ambulance transport

When you could not reach a patient because he or she was not on the premises, e.g., before a specimen was tested

When you realize too late, only after furnishing a service, that you should have given the patient an ABN.

You should also apply -GZ if a patient presents with a condition that is not covered by Medicare, but the physician determines surgery is crucial. If the physician presents the patient with an ABN that the patient refuses to sign and the physician still performs the procedure, appending -GZ could protect you from being held responsible for the procedure's bill. If the claim you submit with -GZ is denied and neither the beneficiary nor the physician is found liable, you might still be able to collect from the beneficiary.

However, "we have found little or no use for the -GZ modifier," Bell says. Bell observes that it is never in a practice's best interest to provide a service that may be denied as not medically necessary to a patient without getting an ABN signed first. "I doubt -GZ will get used very often," Repka agrees.

Rest assured that applying this modifier to a claim will not reduce your chances of reimbursement if the modifier is irrelevant, nor will claims with this modifier automatically be denied.